Andrew Cook - Bladder

Is everybody warming up a little bit? I am from California. I felt like I was starting to look like Deborah Bush’s bunny there with the missing butt. It was getting cold.

I am actually from Santa Cruz and live a couple of blocks from some of the best surfing in the world. I took it up about two years ago. But I do not want to misrepresent, I would not even say I am really a surfer. I have spent some time on the board but I am probably better described as shark bait.

Like Harry said I have been asked to talk about bladder endometriosis. I have no disclosures. Thanks again to Olivia for her help in editing.

Really there are two types of bladder endometriosis. This probably accounts for about 20 percent of all patients. Really there is superficial and invasive endometriosis. By far and away the majority of cases are that of superficial peritoneal endometriosis. This is just your typical superficial peritoneal endometriosis with the scattered lesions around that is treated by wide excision. With these cases this could be more what you typically find with superficial peritoneal endometriosis. It may cause pain, it may be asymptomatic but we really do not expect that it is going to cause a lot of bladder symptoms. If we are seeing that certainly consider interstitial cystitis as with any other case like this. You may get some tenderness of the anterior vaginal wall but you are not going to see it with imaging and really it is going to be laparoscopy for confirmation.

As with all endometriosis you do not always know how deep it goes so over the bladder you just have to be careful and dissect it and make sure that you are getting complete excision of the disease.

This is just, again, this is the carbon 13 CO2 laser and this is just wide excision. The technique with that other slide we see all the individual lesions just to circumscribe around the edge, the widest edge leaving the sonometers…of Melan tissue and excise it. I am pretty anal on getting all the small bleeders, oozers, I think it makes a difference with adhesion formation. For superficial endometriosis this is the kind of approach I am going to use and you can see that there is really very little carbonization.

Invasive bladder endometriosis – this is much less common. I could not really find any solid numbers we are probably talking hundreds, maybe thousands of cases reported but certainly it is not common and especially to involve full thickness endometriosis.

In the talks again Dr. Seckin thanks for putting such a great program together. There have been very interesting talks this morning.

With this invasive endometriosis it is interesting to see where I have even seen complete obliteration of the anterior cul-de-sac but it is not invading into the muscularis. Certainly you just have to dissect it out and make sure to get around it and make sure that you are excising all the disease.

This is the case that we had. I will also show you some video but also you can see the cystoscopy, certainly you could diagnose it when it is invading through the muscularis. In these cases though, the symptoms, about 30 percent are asymptomatic but may present with urinary symptoms; frequency, urgency and painful bladder spasm. Again, you always have to think about IC. In this case you may feel the nodule. In my practice I always do a sonic transvaginal sonogram myself in the office the day before surgery looking for these kinds of things. An MRI may help and in these types of cases certainly cystoscopy would help but usually you are not going to see it with cystoscopy.

This patient that I am presenting is 35 years old gravitas zero, she had been through several previous surgeries including myomectomy, LAVH and some removal of endometriosis although she certainly still had it, still had this nodule which was not initially diagnosed. She had cyclic pain. She was non-functional for about one week out of every month.

This is a cystoscopy. You can see a fairly large nodule it is actually…looking for the ureters to make sure that we are away from the ureter and not going to compromise them. If you are too close then you potentially have to do a re-implantation but this lesion was at the dome in the posterior superior aspect. This is laparoscopically – a couple of things here; one is you can see there is a superficial lesion, identifiers, start to remove that ahead of time just because once you start traumatizing things it can be hard to come back and really identify what is endo versus just surgical trauma. You can see here it is hard to appreciate the extent of this lesion but palpating, looking to see where the resistance is, retraction, neovascularization and that kind of thing.

Just to briefly touch on this and I think in the interest of scientific discipline there were a lot of words being thrown around this morning, we have excision, which almost all of this unless it is cold knife we are doing linear vaporizers for excision. There is ablation, vaporization, really no conduction or very little conduction. You have coagulation, cauterization and fulguration more of a conduction with lateral spread and again, linear vaporization.

Starting with just trying to get around a lesion, I heard a few years back, I forget which conference but somebody said operate in normal tissue. I think it is really one of the basic tenets that if you are operating end disease you are you are not lateral enough. Doing this traction really gives you a lot of clarity on where you are. It just kind of exposing and working it this push dissection openings, separating, to get an idea of where the lesion is because we want to take it out – all the lesion – but in a case like this we want to make sure that we are not reducing or compromising the bladder capacity.

The other thing that I think is just – I was going to say when we get there you get a bleeder and I think in general when we get bleeding you always want to be doing something right away. The first thing is just to breathe, check your heart rate maybe and to make sure you are maintaining exposure because often when you are operating you already have exposures so in a way the thing is to freeze, do not move, you are doing something. If you have a good assistant or you always have that – in my case you use the Gyrus bipolar, it is kind of a micro bipolar and we will see it here in a minute. It is not a huge bleeder but enough to get your attention. We already have it exposed so part of doing something is not moving much. Irrigate it, it is okay, bring your bipolar in. This would apply to uterine vessels like if you are working on the ureter like CY was talking about. Here we are getting into the bladder. Again, you can see there is almost no charring. It is just pure cut, very little lateral (audience question). I am using the carbon 13. I still think it is by far and away from the physics standpoint your best laser because you do not get the absorption of the CO2 gas, you know, the carbon 12 CO2 gas acts as a…effect.

We will jump ahead a little bit. We got it excised all the way out, looking in the bladder. We have a little bit of punctation. This is a result of the surgical trauma itself. We looked for IC ahead of time. Looking to make sure that again, everything is fine before we start closing. And this I just used running, non-locking zero vicryl suture, single layer closure. I think we certainly have looked at single, double and triple layers, single layer is the quickest and has shown to be just as efficacious as a double layer and I guess a trend at a for profit hospital, so conserve suture. Post-operatively left the Foley catheter in for a week and then took it out. She did well. At six month follow up she reported 95 percent improvement and had regained her functionality and really was no longer down and out.

Really kind of what we were talking about today I think this is almost adenomyosis of the bladder wall as opposed to the superficial endometriosis of the bladder peritoneum. Then obviously it is rarely going to be the only disease that is present.

That is it, thank you.

Harry Reich, MD: Sorry to not give you a little bit more time Andrew but I would like to say though that before I give the floor to CY that my philosophy has always been to stay on the disease. We all differ but you tend to stay away from the disease but I like to feel the disease as I am going around, especially nodules of the bladder, the rectum or any of the other areas. Just a difference of opinion. CY?

CY Liu, MD: I see you use zero vicryl to close a bladder defect. Harry, I also want to ask you a question about that suture material to close the bladder. He was using zero Vicryl, now typically you use (mic gone dead) for the first layer.

Second commentator: There are a couple of comments, first of all we use Vicryl now, we used to use a lot of chroma…but now we mostly use Vicryl and they have this new Vicryl Rapide that is great for this kind of thing because it is very quickly absorbing. The knot – there used to be this whole thing about whether the knot is in the bladder or outside the bladder, it does not matter because everything is absorbable. We tend to close in two layers, we like to do a serosal closure if possible. The bladder is extremely resilient you can do almost anything to the bladder and it will heal but the things you cannot do are leave a foreign body, you will get a fistula, devascularized you will get a fistula infection, you will get a fistula abscess, you will get a fistula. Short of that you can actually leave a hole in the bladder and it will close. The last thing I want to say is that if you excise a big portion of the bladder it will compensate over time, within three to six months the bladder will expand and it will be like nothing ever happened. If you feel like you have got a large endometrioma do not leave anything behind because you are worried about bladder capacity, it will compensate. Especially in these young women, it is very forgiving.

CY Liu, MD: You answered the question before I even asked. We have always been taught we have to do it water tight. At the first layer inflate it and make sure there is no leak but according to urologists you do not have to you approximate it and of course bladder capacity and how soon it is recovered. Thank you.

Harry Reich, MD: Do you ever close with single layer?

Second commentator: You know I think like Dr. Cook said it is fine. It is not a problem, especially these young healthy women you close in one layer, it is fine. And again, tension free all the basic surgical principles, you are fine.

Harry Reich, MD: And you can sew interrupted, you do not even have to run it, right?

Second commentator: Right.

Harry Reich, MD: CY, Vicryl? We always use Vicryl to close the bladder.

CY Liu, MD: I use – because the urologist…using plain catgut. Zero…

Harry Reich, MD: I always use Vicryl. Open, you do not use, you do not use it laparoscopically, plain catgut?

CY Liu, MD: Yes.

Second commentator: Catgut is non-braided and it absorbs quickly. That is all, so the principle is the same. It is just not, you know, it is old school, that is all.

(Faint discussion going on.)

Harry Reich, MD: Very nice presentation. Adel you are up next. Before I give you an introduction but go ahead.

Adel Shervin, MD: This video you showed was about nodular on the dome of the bladder, what about at the base of the bladder? How do you approach?

Andrew Cook, MD: Yes, again I think the principles are very similar. The biggest thing is the proximity of the ureters and if you are going to compromise or kink the ureter then you may have to do re-implantation.

Ray Wertheim, MD: What do you think about using barbed sutures? There are never articles about that – using it in the bowel and the bladder.

Andrew Cook, MD: It is a self-retaining, you do not see it you do not have to tie the suture, I guess…

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